Alcohol withdrawal - standard treatment

Applies to those admitted to wards NOT to CDU where CIWA is the preferred choice.

When to treat

  1. Obvious withdrawal: i.e. CIWA –Ar Ssore > 10, autonomic hyperactivity (e.g., sweating or HR> 100), ↑ hand tremor, psychomotor agitation
  2. Not in withdrawal but a clear history (i.e. drinking >10 units per day, previous withdrawal)
  3. Patient in ED awaiting medical admission
  4. Patients in CDU/awaiting CDU who are not suitable for symptom-triggered detoxification

How to treat

Benzodiazepines orally in reducing doses over five days.

Please remember: Diazepam 10 mg = chlordiazepoxide 25mg = lorazepam 1mg.

Chlordiazepoxide and lorazepam reducing regimens
Day   Chlordiazepoxide dose Lorazepam dose R

1 Regular 10 - 40 mg qds 1 - 2mg tds
prn 10 - 40mg 2-hrly 1mg 2-hrly
  Daily Max 250mg in 24hr 8mg
2   10 - 40mg qds ± PRN 1 - 2mg tds
3   10 - 30mg qds ± PRN 1 - 2 mg tds
4   10mg qds ↓ by 1mg per day
5   10mg bd ↓ by 1mg per day
6     ↓ by 1mg per day
7     ↓ by 1mg per day
  • Base initial benzodiazepine dose on severity of withdrawal symptoms in previous 24 hours, or severity of alcohol dependence. Adjust the dose daily according to response
  • Reduce dose in elderly, frail subjects or adjusted according to body mass
  • Liver disease: Patients with abnormal liver enzymes but no clinical evidence of liver failure and normal serum bilirubin, albumin and prothrombin time are suitable for Chlordiazepoxide. Consider lorazepam if liver failure
  • See ‘Symptom-triggered’ guideline for front loaded detoxification used in CDU only
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Adjunctive treatment

Wernicke-Korsakoff Syndrome

Prevention: Pabrinex 1 pair Amps I and II IV daily for 3-5 days followed by oral thiamine 300mg od.

Treatment (i.e. any unexplained confusion): Pabrinex 2 pairs Amps I and II (total 4 vials) IV TID for 3 days and continue 1 pair Amps I and II daily if improving.

Note: Pabrinex carries a CSM warning – rare anaphylaxis risk.

Psychotic symptoms (occurs in Delirium Tremens)

  • Adjust Chlordiazepoxide dose
  • Haloperidol:
    • No liver disease: 5mg PO or IM 4-hrly if required. Max dose 30mg/24-hr
    • Liver disease 0.5mg PO or IM 2-hrly if required. Max dose 2mg /24hrs
  • Note Diazepam 10mg iv over >5mins or Lorazepam iv may be given in severe agitation

Acutely Disturbed/Violent Behaviour


  1. Vital Signs
  2. Level of Arousal
  3. Severity of withdrawal (e.g. using CIWA-Ar scale)
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Be wary of dehydration, hypoglycaemia, delirium due to infection, head injury.

Drowsiness is not a feature of alcohol withdrawal. Nursing staff should omit dose of Chlordiazepoxide if patient is drowsy and look for other causes.

Content By Dr Íomhar O' Sullivan Dr Eugene Cassidy 03/12/2013. Last review Dr ÍOS 21/06/21.